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<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title></title>
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<body>
	<form id="formTab5">
		<fieldset>
			<legend> 费用情况 </legend>
			<table class="layout-table">
				<colgroup>
					<col width="20%" />
					<col width="30%" />
					<col width="20%" />
					<col width="30%" />
				</colgroup>
				<tr>
					<td align="right"><label for="ADA01"> 总费用: </label></td>
					<td><input class="easyui-numberbox" min="0.01" precision="2"
						type="text" id="ADA01" name="ADA01" required="true" /></td>
					<td align="right"><label for="ADA0101"> 自付金额: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA0101" name="ADA0101" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA11"> 诊察（诊疗）费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA11" name="ADA11" /></td>
					<td align="right"><label for="ADA21"> 一般检查费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA21" name="ADA21" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA22"> 临床物理治疗费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA22" name="ADA22" /></td>
					<td align="right"><label for="ADA23"> 介入治疗费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA23" name="ADA23" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA24"> 特殊治疗费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA24" name="ADA24" /></td>
					<td align="right"><label for="ADA25"> 康复治疗费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA25" name="ADA25" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA26"> 中医治疗费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA26" name="ADA26" /></td>
					<td align="right"><label for="ADA27"> 一般治疗费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA27" name="ADA27" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA28"> 精神治疗费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA28" name="ADA28" /></td>
					<td align="right"><label for="ADA13"> 接生费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA13" name="ADA13" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA15"> 麻醉费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA15" name="ADA15" /></td>
					<td align="right"><label for="ADA12"> 手术费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA12" name="ADA12" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA29"> 护理治疗费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA29" name="ADA29" /></td>
					<td align="right"><label for="ADA03"> 护理费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA03" name="ADA03" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA30"> 核素检查: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA30" name="ADA30" /></td>
					<td align="right"><label for="ADA31"> 核素治疗: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA31" name="ADA31" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA32"> 超声费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA32" name="ADA32" /></td>
					<td align="right"><label for="ADA07"> 放射费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA07" name="ADA07" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA08"> 化验费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA08" name="ADA08" /></td>
					<td align="right"><label for="ADA33"> 病理费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA33" name="ADA33" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA34"> 监护及辅助呼吸费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA34" name="ADA34" /></td>
					<td align="right"><label for="ADA35"> 治疗用一次性医用材料费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA35" name="ADA35" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA36"> 介入用一次性医用材料费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA36" name="ADA36" /></td>
					<td align="right"><label for="ADA37"> 手术用一次性医用材料费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA37" name="ADA37" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA38"> 检查用一次性医用材料费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA38" name="ADA38" /></td>
					<td align="right"><label for="ADA02"> 床位费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA02" name="ADA02" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA39"> 挂号费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA39" name="ADA39" /></td>
					<td align="right"><label for="ADA09"> 输氧费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA09" name="ADA09" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA10"> 输血费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA10" name="ADA10" /></td>
					<td align="right"><label for="ADA04"> 西药费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA04" name="ADA04" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA40"> 抗菌药物费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA40" name="ADA40" /></td>
					<td align="right"><label for="ADA41"> 白蛋白类制品费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA41" name="ADA41" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA42"> 球蛋白类制品费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA42" name="ADA42" /></td>
					<td align="right"><label for="ADA43"> 凝血因子类制品费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA43" name="ADA43" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA44"> 细胞因子类制品费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA44" name="ADA44" /></td>
					<td align="right"><label for="ADA05"> 中成药费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA05" name="ADA05" /></td>
				</tr>
				<tr>
					<td align="right"><label for="ADA06"> 中草药费: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA06" name="ADA06" /></td>
					<td align="right"><label for="ADA20"> 其他费用: </label></td>
					<td><input class="easyui-numberbox" min="0" precision="2"
						type="text" id="ADA20" name="ADA20" /></td>
				</tr>
			</table>
		</fieldset>
	</form>
</body>
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